Note: Unless otherwise noted, the data presented below represents 161 studies (210 or 211 stratified observation entries) in the primary, non-overlapping dataset that asked study participants whether or not the DID seek care for a past diarrheal illness.
We also have information on whether individuals would seek care for a hypothetical diarrheal illness from 27 studies (96 stratified observation entries).
Number of stratified observation entries in the primary dataset at each administrative level by country. Countries with >10 observations displayed as 10.
Number of stratified observation entries in the primary dataset within different time periods. Year represents the year sampling was completed. Excludes 6 entries missing study dates.
| variable | value | Total | Percent |
|---|---|---|---|
| Time care | Any care | 170 | 82.1 |
| First source | 29 | 14.0 | |
| Prior to current visit | 7 | 3.4 | |
| Within 24 h | 1 | 0.5 | |
| Self or child | Child | 136 | 65.7 |
| Other | 57 | 27.5 | |
| Self | 14 | 6.8 | |
| Recall time | 14-30 days | 143 | 69.1 |
| Not reported | 35 | 16.9 | |
| 42-365 days | 16 | 7.7 | |
| 2-7 days | 13 | 6.3 | |
| Study population | Caregiver | 112 | 54.1 |
| Other resident | 58 | 28.0 | |
| Head of household | 23 | 11.1 | |
| Caregiver of patient at health facility | 9 | 4.3 | |
| Patient at health facility | 5 | 2.4 | |
| Outbreak described | No | 189 | 91.3 |
| Yes | 18 | 8.7 | |
| Mult choice | No | 178 | 86.0 |
| Yes | 29 | 14.0 | |
| Location desc | Rural | 82 | 39.6 |
| Urban | 67 | 32.4 | |
| Urban and Rural | 50 | 24.2 | |
| Peri-Urban | 5 | 2.4 | |
| IDP or Refugee Camp | 2 | 1.0 | |
| Urban and Peri-Urban | 1 | 0.5 | |
| Income group | Lower middle income | 96 | 46.4 |
| Upper middle income | 43 | 20.8 | |
| Low income | 41 | 19.8 | |
| High income | 27 | 13.0 | |
| Case definition | Diarrhea | 153 | 73.9 |
| Gastroenteritis or non-Vc etiologies | 32 | 15.5 | |
| Severe diarrhea or cholera | 22 | 10.6 |
Note: “Hospitals or clinics” excludes individuals seeking care exclusively or explicitly at private hospitals/clinics, i.e., this includes location categories “Hospital/Clinic” (general) and “Public Hospital/Clinic” (more specific).
For multiple choice questions where there is more than one category of hospital/clinic, we take the largest proportion that sought care across them.
Overall quality score is whether data is internally consistent + whether sample size was justified + whether the non-response was reported.
Our goal here is to estimate the proportion of individuals that seek care when they or their child have diarrhea symptoms in LMICs. Since diarrhea symptoms vary, and some of the categories above had very few observations (e.g., cholera and “other”) we have grouped these into three broad categories of case definitions (below).
We build generalized linear models with a study-level random intercept following the approach of Wiens et al (2023) PLOS Medicine:
Unadjusted
Univariate models adjusted individually for:
Multivatiate model(s) adjusted for factors identified as significant but not confounding/collinear in univariate models.
NB: Here our observations represent data aggregated to study_id, country, and potential covariate stratifications, for a total of 146 unique observations corresponding to 114 studies. For studies with multiple choice questions, we take the maximum sample size and number seeking care for studies where there were multiple categories of “hospital/clinic” as possible answers.
For the primary analysis, we chose priors that matched the distribution of the data. Specifically, we used a Normal(-0.6,1.5) prior on alpha, where the mean of the distribution (-0.67) matches the median of the observation data (0.339) in logit space. The resulting prior predictive distribution has a median of 0.34 and a mean of 0.37.
In sensitivity analyses, we shift the mean of the prior distribution on alpha up or right 20% in probability space (i.e., mean of -0.38 for the normal distribution in logit space, median of 0.41 for the observation data) and down or left 20% (i.e., mean of -0.99 for the normal distribution in logit space, median of 0.27 for the observation data).
| Version | Proportion (%) |
|---|---|
| Unadjusted | 39.3 (9.2 - 77.2) |
| Unadjusted - shift prior left | 37 (8.1 - 75.6) |
| Unadjusted - shift prior right | 42.7 (10.2 - 80.6) |
| Unadjusted - would you | 71.1 (35.1 - 94.2) |
## Number of studies: k = 146
## Number of observations: o = 136822
## Number of events: e = 42388
##
## proportion 95%-CI
## Random effects model 0.3455 [0.2941; 0.4007]
##
## Quantifying heterogeneity:
## tau^2 = 2.0548; tau = 1.4335; I^2 = 99.3% [99.2%; 99.3%]; H = 11.56 [11.26; 11.88]
##
## Test of heterogeneity:
## Q d.f. p-value
## Wald 19392.96 145 0
## LRT 32811.27 145 0
##
## Details on meta-analytical method:
## - Random intercept logistic regression model
## - Maximum-likelihood estimator for tau^2
## - Logit transformation
## - Continuity correction of 0.5 in studies with zero cell frequencies
## (only used to calculate individual study results)
The “estimated” results are the study-level props from the model that includes pop_cat and case_cat.
## I2: 99.9875, 99.98791, 99.98833, ; tau2: 0.77052, 0.79662, 0.8252,
Odds of actually seeking care for diarrhea for each indicated variable, not adjusting for any other variables.
| Variable | Category | Odds ratio | |
|---|---|---|---|
| case_cat | Diarrhea | 1 [Reference] | |
| Gastroenteritis or non-Vc etiologies | 2.39 (0.76 - 5.72) | ||
| Severe diarrhea or cholera | 3.06 (1.4 - 5.95) | ** | |
| location_desc | Non-urban | 1 [Reference] | |
| Urban | 1.15 (0.64 - 1.82) | ||
| Urban and non-urban | 1.54 (0.72 - 2.87) | ||
| mult_choice | 0 | 1 [Reference] | |
| 1 | 1.11 (0.56 - 1.93) | ||
| outbreak_desc | 0 | 1 [Reference] | |
| 1 | 3.1 (1.16 - 7.01) | ** | |
| pop_cat | Caregiver | 1 [Reference] | |
| Caregiver of patient at health facility | 8.28 (2.15 - 21.49) | ** | |
| Head of household | 1.05 (0.51 - 1.93) | ||
| Other resident | 1.27 (0.68 - 2.18) | ||
| recall_time | over30_orNA | 1 [Reference] | |
| under30 | 0.36 (0.2 - 0.61) | ** | |
| self_or_child | Child | 1 [Reference] | |
| Other | 0.88 (0.48 - 1.44) | ||
| Self | 0.92 (0.24 - 2.34) | ||
| time_care | Any care | 1 [Reference] | |
| First source | 0.88 (0.46 - 1.55) | ||
| Prior to current visit | 1.42 (0.16 - 5.63) |
Odds of hypothetically seeking care for diarrhea for each indicated variable, not adjusting for any other variables.
| Variable | Category | Odds ratio | |
|---|---|---|---|
| case_cat | Diarrhea | 1 [Reference] | |
| Gastroenteritis or non-Vc etiologies | 22.7 (0.78 - 121.45) | ||
| Severe diarrhea or cholera | 9.52 (1.69 - 29.66) | ** | |
| location_desc | Non-urban | 1 [Reference] | |
| Urban | 2.33 (0.32 - 8.28) | ||
| Urban and non-urban | 1.21 (0.15 - 4.35) | ||
| mult_choice | 0 | 1 [Reference] | |
| 1 | 6.79 (1.12 - 23.74) | ** | |
| outbreak_desc | 0 | 1 [Reference] | |
| 1 | 2.11 (0.21 - 8.92) | ||
| pop_cat | Caregiver | 1 [Reference] | |
| Caregiver of patient at health facility | 21.57 (0.74 - 120.01) | ||
| Head of household | 0.81 (0.18 - 2.39) | ||
| Other resident | 9.84 (1.63 - 32.54) | ** | |
| recall_time | over30_orNA | 1 [Reference] | |
| under30 | 2.54 (0.07 - 14.93) | ||
| self_or_child | Child | 1 [Reference] | |
| Other | 0.81 (0.12 - 3.05) | ||
| Self | 9.06 (1.41 - 30.75) | ** | |
| time_care | Any care | 1 [Reference] | |
| First source | 2.52 (0.07 - 13.53) | ||
| Prior to current visit | NA |
Odds of seeking care for diarrhea for adults vs. children, not adjusting for any other variables. We have 130 observations total here.
| Variable | Category | Odds ratio | |
|---|---|---|---|
| prop_five | 0 | 1 [Reference] | |
| 1 | 1.07 (0.51 - 2.07) |
Odds of seeking care for diarrhea for adults vs. children, not adjusting for any other variables. We have data from 7 studies that report healthcare seeking at a hospital/clinic by age groups under/over five for LMICs.
| Variable | Category | Odds ratio | |
|---|---|---|---|
| prop_five | 0 | 1 [Reference] | |
| 1 | 1.75 (0.29 - 6.04) |
## Number of studies: k = 14
## Number of observations: o = 26954
## Number of events: e = 7955
##
## proportion 95%-CI
## Random effects model 0.3165 [0.1729; 0.5062]
##
## Quantifying heterogeneity:
## tau^2 = 2.0926; tau = 1.4466; I^2 = 99.2% [99.0%; 99.3%]; H = 10.96 [9.99; 12.02]
##
## Test of heterogeneity:
## Q d.f. p-value
## Wald 1561.41 13 0
## LRT 1775.73 13 0
##
## Results for subgroups (random effects model):
## k proportion 95%-CI tau^2 tau Q I^2
## prop_five = 0 7 0.2844 [0.1079; 0.5665] 2.4459 1.5639 1233.24 99.5%
## prop_five = 1 7 0.3461 [0.1583; 0.5984] 1.6565 1.2870 255.83 97.7%
##
## Test for subgroup differences (random effects model):
## Q d.f. p-value
## Between groups 0.13 1 0.7218
##
## Details on meta-analytical method:
## - Random intercept logistic regression model
## - Maximum-likelihood estimator for tau^2
## - Logit transformation
Residual heterogeneity (tau2) is the same between groups
##
## Mixed-Effects Model (k = 14; tau^2 estimator: REML)
##
## tau^2 (estimated amount of residual heterogeneity): 2.690 (SE = 1.102)
## tau (square root of estimated tau^2 value): 1.640
## I^2 (residual heterogeneity / unaccounted variability): 99.99%
## H^2 (unaccounted variability / sampling variability): 12778.89
## R^2 (amount of heterogeneity accounted for): 0.00%
##
## Test for Residual Heterogeneity:
## QE(df = 12) = 66652.799, p-val < .001
##
## Test of Moderators (coefficient 2):
## QM(df = 1) = 0.246, p-val = 0.620
##
## Model Results:
##
## estimate se zval pval ci.lb ci.ub
## intrcpt -0.889 0.620 -1.433 0.152 -2.105 0.327
## prop_five 0.436 0.878 0.496 0.620 -1.285 2.157
##
## ---
## Signif. codes: 0 '***' 0.001 '**' 0.01 '*' 0.05 '.' 0.1 ' ' 1
Allowing amounts of residual heterogeneity (tau2) to be different between groups
##
## Multivariate Meta-Analysis Model (k = 14; method: REML)
##
## Variance Components:
##
## outer factor: study_id (nlvls = 7)
## inner factor: prop_five (nlvls = 2)
##
## estim sqrt k.lvl fixed level
## tau^2.1 2.977 1.726 7 no 0
## tau^2.2 2.401 1.550 7 no 1
##
## Test for Residual Heterogeneity:
## QE(df = 12) = 66652.799, p-val < .001
##
## Test of Moderators (coefficient 2):
## QM(df = 1) = 0.245, p-val = 0.620
##
## Model Results:
##
## estimate se zval pval ci.lb ci.ub
## intrcpt -0.889 0.653 -1.362 0.173 -2.168 0.390
## prop_five 0.435 0.878 0.495 0.620 -1.286 2.156
##
## ---
## Signif. codes: 0 '***' 0.001 '**' 0.01 '*' 0.05 '.' 0.1 ' ' 1
In analyses below, the dependent variable is listed in the header.
| Variable | Category | Odds ratio | |
|---|---|---|---|
| case_cat | Diarrhea | 1 [Reference] | |
| Gastroenteritis or non-Vc etiologies | 4.38 (0.02 - 34.05) | ||
| Severe diarrhea or cholera | 0.74 (0.01 - 4.2) | ||
| mult_choice | 0 | 1 [Reference] | |
| 1 | 0.38 (0.01 - 1.94) | ||
| outbreak_desc | 0 | 1 [Reference] | |
| 1 | 0.55 (0.01 - 3.13) | ||
| pop_cat | Caregiver | 1 [Reference] | |
| Caregiver of patient at health facility | 1.96 (0.02 - 12.1) | ||
| Head of household | 1.97 (0.01 - 12.41) | ||
| Other resident | 73.54 (9.33 - 282.68) | ** | |
| recall_time | over30_orNA | 1 [Reference] | |
| under30 | 0.2 (0.03 - 0.73) | ** | |
| time_care | Any care | 1 [Reference] | |
| First source | 0.36 (0.01 - 1.9) | ||
| Prior to current visit | 2.22 (0.02 - 14.27) |
| Variable | Category | Odds ratio | |
|---|---|---|---|
| case_cat | Diarrhea | 1 [Reference] | |
| Gastroenteritis or non-Vc etiologies | 1.94 (0.02 - 11.69) | ||
| Severe diarrhea or cholera | 24.38 (4.04 - 88.67) | ** | |
| mult_choice | 0 | 1 [Reference] | |
| 1 | 1.83 (0.17 - 7.68) | ||
| pop_cat | Caregiver | 1 [Reference] | |
| Caregiver of patient at health facility | 1.44 (0.01 - 8.82) | ||
| Head of household | 5.79 (0.79 - 21.78) | ||
| Other resident | 1.59 (0.14 - 6.08) | ||
| recall_time | over30_orNA | 1 [Reference] | |
| under30 | 0.09 (0.01 - 0.26) | ** | |
| self_or_child | Child | 1 [Reference] | |
| Other | 2.26 (0.34 - 7.82) | ||
| Self | 1.61 (0.02 - 9.22) | ||
| time_care | Any care | 1 [Reference] | |
| First source | 0.49 (0.03 - 1.94) | ||
| Prior to current visit | 2.23 (0.02 - 14) |
| Variable | Category | Odds ratio | |
|---|---|---|---|
| mult_choice | 0 | 1 [Reference] | |
| 1 | 1.47 (0.11 - 6.12) | ||
| outbreak_desc | 0 | 1 [Reference] | |
| 1 | 25.37 (3.61 - 92.94) | ** | |
| pop_cat | Caregiver | 1 [Reference] | |
| Caregiver of patient at health facility | 5.49 (0.14 - 29.16) | ||
| Head of household | 4.77 (0.58 - 18.2) | ||
| Other resident | 4.56 (0.57 - 16.57) | ||
| recall_time | over30_orNA | 1 [Reference] | |
| under30 | 0.03 (0.01 - 0.1) | ** | |
| self_or_child | Child | 1 [Reference] | |
| Other | 4.27 (0.71 - 14.5) | ||
| Self | 1.37 (0.01 - 8.2) | ||
| time_care | Any care | 1 [Reference] | |
| First source | 1.12 (0.13 - 3.86) | ||
| Prior to current visit | 9.63 (0.19 - 54.96) |
| Variable | Category | Odds ratio | |
|---|---|---|---|
| mult_choice | 0 | 1 [Reference] | |
| 1 | 0.84 (0.05 - 3.78) | ||
| outbreak_desc | 0 | 1 [Reference] | |
| 1 | 1.17 (0.01 - 6.88) | ||
| pop_cat | Caregiver | 1 [Reference] | |
| Caregiver of patient at health facility | 10.76 (0.26 - 57.17) | ||
| Head of household | 0.66 (0.01 - 3.76) | ||
| Other resident | 19.97 (2.96 - 74.9) | ** | |
| recall_time | over30_orNA | 1 [Reference] | |
| under30 | 0.17 (0.02 - 0.58) | ** | |
| self_or_child | Child | 1 [Reference] | |
| Other | 12.89 (1.92 - 46.55) | ** | |
| Self | 2.19 (0.02 - 14.11) | ||
| time_care | Any care | 1 [Reference] | |
| First source | 0.59 (0.04 - 2.38) | ||
| Prior to current visit | 2.98 (0.02 - 18.84) |
Is there still an effect of being in an outbreak when we subset the data to just case definitions specific to cholera or severe diarrhea (including death)?
| Variable | Category | Odds ratio | |
|---|---|---|---|
| outbreak_desc | 0 | 1 [Reference] | |
| 1 | 2.01 (0.37 - 6.38) |
Is there still an effect of recall period when we subset the data to just case definitions for general diarrhea (not severe or resulting in death)?
| Variable | Category | Odds ratio | |
|---|---|---|---|
| recall_time | over30_orNA | 1 [Reference] | |
| under30 | 0.72 (0.34 - 1.31) |
Odds that an individual seeks care for themselves or their child overall or by alternate case definitions, adjusting for study respondent.
| Variable | Category | Odds ratio | |
|---|---|---|---|
| case_cat | Diarrhea | 1 [Reference] | |
| Gastroenteritis or non-Vc etiologies | 2.2 (0.65 - 5.5) | ||
| Severe diarrhea or cholera | 2.99 (1.32 - 5.83) | ** | |
| pop_cat | Caregiver | 1 [Reference] | |
| Caregiver of patient at health facility | 6.94 (1.95 - 17.82) | ** | |
| Head of household | 0.95 (0.47 - 1.7) | ||
| Other resident | 1.01 (0.53 - 1.76) |
Odds that an individual hypothetically seeks care for themselves or their child overall or by alternate case definitions, adjusting for study respondent.
| Variable | Category | Odds ratio | |
|---|---|---|---|
| case_cat | Diarrhea | 1 [Reference] | |
| Gastroenteritis or non-Vc etiologies | 14.72 (0.19 - 91.71) | ||
| Severe diarrhea or cholera | 5.17 (0.59 - 20.53) | ||
| pop_cat | Caregiver | 1 [Reference] | |
| Caregiver of patient at health facility | 14.45 (0.2 - 94.48) | ||
| Head of household | 0.75 (0.15 - 2.19) | ||
| Other resident | 5.21 (0.52 - 21.5) |
Stratifications correspond to questions that refer to care seeking for a caregiver.
| Version | Model | Variable | Proportion (%) |
|---|---|---|---|
| Main result | 1 | Unadjusted | 39.3 (9.2 - 77.2) |
| 2 | Diarrhea | 38.6 (8.4 - 77.1) | |
| 2 | Gastroenteritis or non-Vc etiologies | 69.8 (24.3 - 98.9) | |
| 2 | Severe diarrhea or cholera | 79.5 (37.4 - 99.2) | |
| 3 | Adjusted for methods | 38.3 (8.6 - 76.5) | |
| Shift prior left | 1 | Unadjusted | 37 (8.1 - 75.6) |
| 2 | Diarrhea | 35.7 (7.3 - 74.4) | |
| 2 | Gastroenteritis or non-Vc etiologies | 66.8 (20.6 - 98.8) | |
| 2 | Severe diarrhea or cholera | 76.5 (32.2 - 99.1) | |
| 3 | Adjusted for methods | 35.8 (7.2 - 73.6) | |
| Shift prior right | 1 | Unadjusted | 42.7 (10.2 - 80.6) |
| 2 | Diarrhea | 41.3 (9.6 - 78.7) | |
| 2 | Gastroenteritis or non-Vc etiologies | 71.8 (26.2 - 98.9) | |
| 2 | Severe diarrhea or cholera | 81.6 (41 - 99.5) | |
| 3 | Adjusted for methods | 41.5 (10 - 79.1) |
## Number of studies: k = 146
## Number of observations: o = 136822
## Number of events: e = 42388
##
## proportion 95%-CI
## Random effects model 0.3455 [0.2941; 0.4007]
##
## Quantifying heterogeneity:
## tau^2 = 2.0548; tau = 1.4335; I^2 = 99.3% [99.2%; 99.3%]; H = 11.56 [11.26; 11.88]
##
## Test of heterogeneity:
## Q d.f. p-value
## Wald 19392.96 145 0
## LRT 32811.27 145 0
##
## Results for subgroups (random effects model):
## k proportion 95%-CI
## case_cat = Diarrhea 122 0.3378 [0.2815; 0.3991]
## case_cat = Severe diarrhea or cholera 16 0.3721 [0.2200; 0.5545]
## case_cat = Gastroenteritis or non-Vc etiol ... 8 0.3927 [0.3092; 0.4830]
## tau^2 tau Q I^2
## case_cat = Diarrhea 2.1470 1.4653 16670.15 99.3%
## case_cat = Severe diarrhea or cholera 2.2102 1.4867 2436.73 99.4%
## case_cat = Gastroenteritis or non-Vc etiol ... 0.2267 0.4762 209.81 96.7%
##
## Test for subgroup differences (random effects model):
## Q d.f. p-value
## Between groups 1.08 2 0.5817
##
## Details on meta-analytical method:
## - Random intercept logistic regression model
## - Maximum-likelihood estimator for tau^2
## - Logit transformation
## - Continuity correction of 0.5 in studies with zero cell frequencies
## (only used to calculate individual study results)
To do this with logit(proportion) as outcome, need to drop Cuban study where 100% sought care.
Residual heterogeneity (tau2) is the same between groups
##
## Mixed-Effects Model (k = 145; tau^2 estimator: REML)
##
## tau^2 (estimated amount of residual heterogeneity): 1.934 (SE = 0.230)
## tau (square root of estimated tau^2 value): 1.391
## I^2 (residual heterogeneity / unaccounted variability): 99.99%
## H^2 (unaccounted variability / sampling variability): 19626.08
## R^2 (amount of heterogeneity accounted for): 4.54%
##
## Test for Residual Heterogeneity:
## QE(df = 142) = 7100957.714, p-val < .001
##
## Test of Moderators (coefficients 2:3):
## QM(df = 2) = 8.868, p-val = 0.012
##
## Model Results:
##
## estimate se zval pval
## intrcpt -0.796 0.126 -6.318 <.001
## case_catGastroenteritis or non-Vc etiologies 0.209 0.541 0.387 0.699
## case_catSevere diarrhea or cholera 1.101 0.370 2.974 0.003
## ci.lb ci.ub
## intrcpt -1.043 -0.549 ***
## case_catGastroenteritis or non-Vc etiologies -0.851 1.269
## case_catSevere diarrhea or cholera 0.376 1.827 **
##
## ---
## Signif. codes: 0 '***' 0.001 '**' 0.01 '*' 0.05 '.' 0.1 ' ' 1
Allowing amounts of residual heterogeneity (tau2) to be different between groups
##
## Multivariate Meta-Analysis Model (k = 145; method: REML)
##
## Variance Components:
##
## outer factor: study_id (nlvls = 113)
## inner factor: case_cat (nlvls = 3)
##
## estim sqrt k.lvl fixed level
## tau^2.1 2.189 1.480 122 no Diarrhea
## tau^2.2 1.030 1.015 7 no Gastroenteritis or non-Vc etiologies
## tau^2.3 2.212 1.487 16 no Severe diarrhea or cholera
##
## Test for Residual Heterogeneity:
## QE(df = 142) = 7100957.714, p-val < .001
##
## Test of Moderators (coefficients 2:3):
## QM(df = 2) = 5.173, p-val = 0.075
##
## Model Results:
##
## estimate se zval pval
## intrcpt -0.771 0.150 -5.131 <.001
## case_catGastroenteritis or non-Vc etiologies 0.184 0.413 0.446 0.656
## case_catSevere diarrhea or cholera 1.073 0.473 2.267 0.023
## ci.lb ci.ub
## intrcpt -1.066 -0.477 ***
## case_catGastroenteritis or non-Vc etiologies -0.625 0.993
## case_catSevere diarrhea or cholera 0.145 2.000 *
##
## ---
## Signif. codes: 0 '***' 0.001 '**' 0.01 '*' 0.05 '.' 0.1 ' ' 1